Irb Consent Form Template

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[BRIEF TITLE OF THE RESEARCH PROJECT] TO:________[FULL NAME OF
VOLUNTEER]_______________________
My name is [give full name of principal investigator]. I am a faculty member [student, etc.] in
the Department of [name of department] at Beloit College and can be contacted at [give address
and phone number]. [For students, include also contact information for faculty sponsor.]
I have asked you to agree to be a volunteer in some research [a study, and experiment, etc.] that I
plan to conduct. Before I can accept your consent, I want to make known to you the following
information pertaining to the project.
1. [Explanation of the Purpose and the Procedures.] Explanation of the purposes of the
research and the expected duration of the participant’s participation, a description of the
procedures to be followed, and identification of any procedures that are experimental
(i.e., haven’t been tried by others in previous studies). Include a detailed account of what
you are asking the volunteer to consent to do. Avoid language and word usage that the
volunteer in light of age, educational background, ability in English, etc., is not likely to
understand well enough to provide a fully informed consent. Exclude any statements that
may be considered coercive (unduly encourage participants to participate).
2. [Expected Risks.] A description of any reasonably foreseeable risks or discomforts to the
participant. This includes procedures that may involve risks to an embryo or fetus if the
participant is or may become pregnant. If there are no risks, simply state that fact (e.g.,
“No discomforts or risks are expected.”)
3. [Expected Benefits] A description of any benefits to the participant or to others which
may be expected from the research. If there are none, state:
“Other than the experience of participation in a research project, there are no particular
benefits for you.” NOTE: If the volunteer will receive payment for participation in
the research project, this is considered a benefit. If the volunteers are to be paid or
compensated, specify dollar amount and address the matter of proration if the
volunteer withdraws or if the study is terminated by the investigator.
4. [Appropriate Alternative Procedures.]
NOTE: If no medical or psychological treatment is involved, you may omit this entire
paragraph. A disclosure of appropriate alternative procedures or courses of treatment, if
any, that might be advantageous to the participant.
5. [Confidentiality.] A statement describing the extent, if any, to which confidentiality of
records identifying the participant will be maintained. If complete confidentiality cannot
be maintained, describe any limits to confidentiality. Include a statement such as the
following:
“Every effort will be made to maintain the confidentiality of the records, except for any
disclosure required by law. Confidentiality of records will be maintained by
__________________[say how]. Limits to confidentiality include
________________[note any limitations].”

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